Although many are still concerned with an ARB–MI paradox, our study of close to 60 000 patients with MI should serve as reassurance that ARBs are not associated with adverse outcomes compared with ACEIs. Potential benefits of ARBs as compared with ACEIs in older women with MI should be further evaluated.
This document discusses approaches to dosing adjustment in renal failure. It outlines methods for estimating glomerular filtration rate (GFR) and limitations of using serum creatinine to assess kidney function. Specifically, it addresses how creatinine is eliminated and factors like tubular secretion that can influence creatinine levels. The document also compares creatinine clearance and estimated GFR, discussing equations like Cockcroft-Gault and MDRD. It provides recommendations on which equation to use based on a patient's weight and stability of creatinine levels. Resources for calculating creatinine clearance and estimated GFR are also presented.
1. A Case report of Heart Failure
2. Discussion on Heart Failure
3. Role of Peptides in Heart Failure
4. Importance of 30 days in heart failure
5. Role of ENTRESTO in Stable Heart Failure patient (PARADIGM-HF study)(HFrEF)
6. Biomarkers in Heart Failure
7. Role of ARNI in Hospitalized Heart Failure patient (PIONEER-HF study)
8. Role of ARNI in HFpEF (PARAMOUNT Trial)
9. Safety and usefulness of ACEI/ARB/ARNI
10. Role of SGPL2 inhibitors in HF with/without DM
The document compares the efficacy of different angiotensin receptor blockers (ARBs). It provides an overview of the renin-angiotensin-aldosterone system (RAAS) and how RAAS modulators such as ARBs work. It then reviews clinical trial data comparing the blood pressure lowering effects, 24-hour blood pressure control, and ability to achieve blood pressure goals of various ARBs. The document also examines the evidence for using ARBs to treat heart failure, including several meta-analyses, with the conclusion being that ARBs do not reduce mortality or morbidity in heart failure beyond placebo or ACE inhibitors.
This document discusses angiotensin II receptor blockers (ARBs), which are used to treat hypertension and other conditions. It lists the major ARBs available worldwide and in Bangladesh specifically. Data on the top selling ARBs in Bangladesh from 2001-2012 shows losartan as the highest selling, with strong growth from olmesartan and irbesartan as well. Clinical trials findings suggest azilsartan may provide better blood pressure control than other ARBs. A price comparison table shows the monthly and annual costs of common ARBs.
The document discusses the rationale and history of using combination therapy to treat hypertension. It notes that combination therapy has been used since the 1950s and studies in the 1960s showed improved blood pressure control and reduced morbidity. Guidelines now recommend initial combination therapy using single pill combinations over stepwise monotherapy due to greater effectiveness in reducing blood pressure and heart disease risk. For patients still uncontrolled on dual therapy, guidelines recommend adding a third drug, often in a single pill combination, to help achieve target blood pressure goals.
AZILSARTAN - CILNIDIPINE COMBINATION - The new frontier in hypertension manag...Praveen Nagula
1) Azilsartan-CCB combination provides a new approach for hypertension management by utilizing the strong blood pressure lowering effects of both azilsartan and calcium channel blockers like cilnidipine.
2) Clinical trials show the combination of azilsartan and cilnidipine more effectively lowers both clinic and 24-hour blood pressure compared to either drug alone.
3) The combination has advantages like once daily dosing, smooth reduction in blood pressure with a low risk of side effects like hypotension, and may provide additional benefits like reducing cardiovascular risk.
Management strategy in HF with ARNI - Recent updates Praveen Nagula
- The document discusses management strategies for heart failure with reduced ejection fraction (HFrEF), including recent updates.
- It summarizes key differences between Indian and Western HF patients, noting that Indians develop HF at a younger age and with lower ejection fractions. Prognosis is also worse for Indian patients compared to those in the West.
- Core therapies for HFrEF are discussed, including a paradigm shift with the approval of sacubitril-valsartan which has been shown to reduce cardiovascular death compared to ACE inhibitors or ARBs alone in clinical trials.
This document discusses approaches to dosing adjustment in renal failure. It outlines methods for estimating glomerular filtration rate (GFR) and limitations of using serum creatinine to assess kidney function. Specifically, it addresses how creatinine is eliminated and factors like tubular secretion that can influence creatinine levels. The document also compares creatinine clearance and estimated GFR, discussing equations like Cockcroft-Gault and MDRD. It provides recommendations on which equation to use based on a patient's weight and stability of creatinine levels. Resources for calculating creatinine clearance and estimated GFR are also presented.
1. A Case report of Heart Failure
2. Discussion on Heart Failure
3. Role of Peptides in Heart Failure
4. Importance of 30 days in heart failure
5. Role of ENTRESTO in Stable Heart Failure patient (PARADIGM-HF study)(HFrEF)
6. Biomarkers in Heart Failure
7. Role of ARNI in Hospitalized Heart Failure patient (PIONEER-HF study)
8. Role of ARNI in HFpEF (PARAMOUNT Trial)
9. Safety and usefulness of ACEI/ARB/ARNI
10. Role of SGPL2 inhibitors in HF with/without DM
The document compares the efficacy of different angiotensin receptor blockers (ARBs). It provides an overview of the renin-angiotensin-aldosterone system (RAAS) and how RAAS modulators such as ARBs work. It then reviews clinical trial data comparing the blood pressure lowering effects, 24-hour blood pressure control, and ability to achieve blood pressure goals of various ARBs. The document also examines the evidence for using ARBs to treat heart failure, including several meta-analyses, with the conclusion being that ARBs do not reduce mortality or morbidity in heart failure beyond placebo or ACE inhibitors.
This document discusses angiotensin II receptor blockers (ARBs), which are used to treat hypertension and other conditions. It lists the major ARBs available worldwide and in Bangladesh specifically. Data on the top selling ARBs in Bangladesh from 2001-2012 shows losartan as the highest selling, with strong growth from olmesartan and irbesartan as well. Clinical trials findings suggest azilsartan may provide better blood pressure control than other ARBs. A price comparison table shows the monthly and annual costs of common ARBs.
The document discusses the rationale and history of using combination therapy to treat hypertension. It notes that combination therapy has been used since the 1950s and studies in the 1960s showed improved blood pressure control and reduced morbidity. Guidelines now recommend initial combination therapy using single pill combinations over stepwise monotherapy due to greater effectiveness in reducing blood pressure and heart disease risk. For patients still uncontrolled on dual therapy, guidelines recommend adding a third drug, often in a single pill combination, to help achieve target blood pressure goals.
AZILSARTAN - CILNIDIPINE COMBINATION - The new frontier in hypertension manag...Praveen Nagula
1) Azilsartan-CCB combination provides a new approach for hypertension management by utilizing the strong blood pressure lowering effects of both azilsartan and calcium channel blockers like cilnidipine.
2) Clinical trials show the combination of azilsartan and cilnidipine more effectively lowers both clinic and 24-hour blood pressure compared to either drug alone.
3) The combination has advantages like once daily dosing, smooth reduction in blood pressure with a low risk of side effects like hypotension, and may provide additional benefits like reducing cardiovascular risk.
Management strategy in HF with ARNI - Recent updates Praveen Nagula
- The document discusses management strategies for heart failure with reduced ejection fraction (HFrEF), including recent updates.
- It summarizes key differences between Indian and Western HF patients, noting that Indians develop HF at a younger age and with lower ejection fractions. Prognosis is also worse for Indian patients compared to those in the West.
- Core therapies for HFrEF are discussed, including a paradigm shift with the approval of sacubitril-valsartan which has been shown to reduce cardiovascular death compared to ACE inhibitors or ARBs alone in clinical trials.
This document provides an overview of the management of dyslipidemia. It discusses lipoprotein classification and composition. It also outlines the non-pharmacological and pharmacological treatment approaches for different dyslipidemia scenarios, including various drug classes like statins, PCSK9 inhibitors, fibrates and their effects. It discusses treatment approaches for different patient groups such as those with cardiovascular disease, diabetes, chronic kidney disease, inflammatory conditions and others. The guidelines for screening and management of dyslipidemia in various clinical situations are summarized.
The document discusses the benefits of angiotensin receptor blockers (ARBs) in treating chronic kidney disease, specifically in patients with type 2 diabetes. It summarizes the results of the RENAAL clinical trial which found that losartan reduced the risk of doubling of serum creatinine, end-stage renal disease, and other kidney-related outcomes in patients with type 2 diabetes and nephropathy by 16-28% compared to placebo. The trial demonstrated that losartan provided renoprotective effects beyond blood pressure control alone in this high-risk population.
Javed Butler, MD, MPH, MBA, discusses heart failure in this CME activity titled, "New Frontiers in Managing Heart Failure: Are SGLT2 Inhibitors the Next Leap Forward in Optimizing Patient Care?" For the full presentation, downloadable infographics, monograph, complete CME information, and to apply for credit, please visit us at http://bit.ly/2JG2v9l. CME credit will be available until May 29, 2020.
Cardio-Renal Protection Through Renin–Angiotensin–Aldosterone System Inhibitionmagdy elmasry
Physiological and detrimental roles of RAAS molecules in cardiac, vascular tissues and kidneys.‘cardiovascular continuum’ Barriers In Optimizing RAAS Inhibition.The effects of angiotensin II inhibition and improvement in bradykinin availability
Role of raas inhibition in management of hypertensionKyaw Win
1) RAAS inhibition plays a central role in the pathogenesis of cardiovascular disease by modulating processes like vasoconstriction, inflammation, endothelial dysfunction, and atherosclerosis.
2) Both ACE inhibitors and ARBs have been shown to reduce target organ damage and improve endothelial function through various mechanisms such as increasing NO and reducing oxidative stress and inflammation.
3) Clinical trials provide evidence that RAAS inhibition can reduce atherosclerosis progression, cardiac hypertrophy, and events in conditions like coronary artery disease and heart failure.
Hypertension: New Concepts, Guidelines, and Clinical Management Hypertensio...MedicineAndFamily
This document summarizes guidelines for diagnosing and treating hypertension. It discusses the prevalence of hypertension and cardiovascular disease in the US population. It reviews risk factors for hypertension and cardiovascular events. It also summarizes findings from clinical trials demonstrating the benefits of treating hypertension, including reduced risks of stroke, heart failure, and myocardial infarction. Thiazide diuretics are recommended as first-line treatment based on their effectiveness and lower costs.
Effects of Sodium Glucose contransporter (SGLT2) inhibition on renal outcomes in patients with (diabetic) chronic kidney disease.
Presentation given during the East by Southwest, Annual Update in Nephrology, September 17th 2017, Santa Fe, NM
http://medicine.unm.edu/academic-divisions/nephrology/east-by-southwest.html
1) Statins are highly effective in reducing LDL-C and cardiovascular risk, playing a cornerstone role in lipid management. They work by inhibiting HMG-CoA reductase.
2) Atorvastatin has been extensively studied in large trials and shown to significantly reduce major cardiovascular events when doses are increased from 10 mg to 80 mg.
3) Studies in India found that high dose atorvastatin (80 mg) was well tolerated and more effective at reducing LDL-C and hs-CRP than lower doses in ACS patients. However, many ACS patients in India were not receiving statins as recommended.
- Bisoprolol is a highly selective beta-1 blocker used to treat heart failure, hypertension, and myocardial infarction.
- Studies show bisoprolol lowers blood pressure and heart rate more effectively than atenolol, with greater reductions throughout the day.
- The CIBIS II trial found adding bisoprolol to standard heart failure treatment reduced all-cause mortality by 34% and reduced hospitalizations compared to placebo.
Efonidipine is a calcium channel blocker that uniquely blocks L-type, N-type, and T-type calcium channels. It has potent antihypertensive effects and provides cardiovascular protection through multiple mechanisms. These include reducing myocardial oxygen demand, improving endothelial function, attenuating platelet activation, and inhibiting aldosterone levels. Efonidipine also has protective effects on the kidneys, brain, and metabolic function. It has an excellent safety profile with minimal side effects like pedal edema compared to other calcium channel blockers.
This document discusses hypertension in patients with chronic kidney disease. It begins by noting that hypertension and diabetes are leading causes of end-stage renal disease. It then discusses how poorly controlled hypertension can cause or accelerate renal failure. The document provides an overview of diseases attributable to hypertension and outlines the paradigm shift in hypertension therapy to focus on more than just lowering blood pressure. It also discusses lifestyle modifications, target organ damage, left ventricular hypertrophy, dipping patterns, morbidity and mortality related to hypertension, and approaches to hypertension treatment and management.
Vymada Tablet (ARNI: Angiotensin Receptor Neprilysin Inhibitor) is an anti-hypertensive drug used in combination with Sacubitril & Valsartan to reduce the risk of cardiovascular events in patients with chronic heart failure (NYHA Class II-IV) and reduced ejection fraction.
The document summarizes guidelines from the International Society of Hypertension (ISH), World Health Organization (WHO), American College of Cardiology/American Heart Association (ACC/AHA), and European Society of Cardiology/European Society of Hypertension (ESC/ESH) on the diagnosis and treatment of hypertension. It compares the guidelines on prevalence of hypertension, treatment thresholds and targets, drug choice and sequencing, and targets for specific patient groups. While the guidelines have some differences, they also have many similarities, including treatment targets of under 140/90 mmHg for most patients and under 130/80 mmHg for high-risk groups.
Dapagliflozin is an SGLT2 inhibitor that has shown benefits in managing type 2 diabetes and reducing cardiovascular outcomes. The document summarizes results from several key studies on dapagliflozin. The DECLARE-TIMI trial showed that dapagliflozin reduced the risk of cardiovascular death or hospitalization for heart failure compared to placebo in patients with type 2 diabetes with high cardiovascular risk. The DAPA-HF trial found that dapagliflozin reduced the risks of worsening heart failure or cardiovascular death compared to placebo in patients with heart failure regardless of diabetes status. Dapagliflozin also improved outcomes related to heart failure in the DEFINE-HF trial.
Recent advances in treatment of Hypertension -- Drugs inhibiting RAAS, Diuret...Deepthivagge
This document summarizes guidelines for diagnosing hypertension, mechanisms of action for antihypertensive drug classes, and clinical trials of new antihypertensive drugs. The JNC 7 criteria classify blood pressure and define thresholds for normal, prehypertension, and stages 1 and 2 of hypertension. Drugs that inhibit the renin-angiotensin-aldosterone system lower blood pressure by blocking counter-regulatory mechanisms. New direct renin inhibitors and their mechanisms of action are discussed along with clinical trial results comparing their efficacy to ACE inhibitors and ARBs. Calcium channel blockers mechanisms and advantages are also summarized, along with current uses and new drugs in clinical trials.
This document discusses several clinical studies that compare the effects of different statin drugs on cardiovascular outcomes and the progression of atherosclerosis. The STELLAR study showed that rosuvastatin more effectively lowered LDL-C and raised HDL-C than other statins. Two real-world studies found that rosuvastatin use was associated with a 28-40% lower risk of cardiovascular events compared to other statins. The METEOR study found that rosuvastatin slowed the progression of atherosclerosis whereas the ENHANCE study found that ezetimibe added to simvastatin provided no benefit.
This document provides an overview of canagliflozin, an SGLT2 inhibitor used to treat type 2 diabetes. It discusses the pathogenesis of type 2 diabetes, progressive beta cell dysfunction, and the kidney's role in glucose regulation. It then reviews canagliflozin's mechanism of action as an SGLT2 inhibitor, increasing urinary glucose excretion and reducing blood glucose levels. The document summarizes canagliflozin's clinical trials, pharmacokinetics, efficacy, safety profile, and effects on renal function and lipids.
What’s new in Lipidology, Lessons from “recent guidelines“Arindam Pande
1. The 2018 ACC/AHA cholesterol guidelines provide 10 key take-home messages focusing on lifestyle management, statin therapy for various risk groups, and risk assessment approaches.
2. The guidelines emphasize lifestyle therapy and statins for secondary prevention, with an LDL-C goal of 70 mg/dL for very high risk patients to consider adding nonstatins.
3. They provide guidance on statin use for various primary prevention groups based on risk levels and discussion, including an expanded definition of intermediate risk factors.
1) The SPRINT trial was a randomized controlled trial that compared an intensive blood pressure treatment target of less than 120 mmHg to a standard target of less than 140 mmHg. 9,361 participants aged 50 and older with high cardiovascular risk were enrolled and followed for a median of 3.26 years.
2) The primary outcome was a composite of myocardial infarction, other acute coronary syndromes, stroke, heart failure, or death from cardiovascular causes. Key secondary outcomes included all-cause mortality and renal outcomes.
3) Results found that the intensive treatment target reduced the primary composite outcome by 25% and all-cause mortality by 27%, showing benefit of the lower blood pressure target. The trial was stopped early due
Nejm Effects of Aspirin for Primary Prevention in Persons with Diabetes MellitusBhargav Kiran
This document summarizes the results of the ASCEND trial, which investigated the effects of low-dose aspirin (100 mg daily) for primary prevention of cardiovascular events in 15,480 adults with diabetes but no history of cardiovascular disease. Over a mean follow-up of 7.4 years:
- Serious vascular events were lower in the aspirin group (8.5%) compared to placebo (9.6%), but major bleeding events were higher with aspirin (4.1% vs 3.2%).
- There was no significant difference in gastrointestinal cancer rates between groups.
- Aspirin prevented some vascular events but increased bleeding, largely offsetting the benefits. The absolute risks and benefits were closely balanced
Providing additional information aboutthe benefits of statin.docxwoodruffeloisa
Providing additional information about
the benefits of statins in a leaflet for
patients with coronary heart disease:
a qualitative study of the impact on
attitudes and beliefs
Rebecca Dickinson,
1
David K Raynor,
1
Peter Knapp,
2
Jan MacDonald
3
To cite: Dickinson R,
Raynor DK, Knapp P, et al.
Providing additional
information about the
benefits of statins in a leaflet
for patients with coronary
heart disease: a qualitative
study of the impact on
attitudes and beliefs. BMJ
Open 2016;6:e012000.
doi:10.1136/bmjopen-2016-
012000
▸ Prepublication history and
additional material is
available. To view please visit
the journal (http://dx.doi.org/
10.1136/bmjopen-2016-
012000).
Received 22 March 2016
Revised 3 November 2016
Accepted 8 November 2016
1School of Healthcare,
University of Leeds, Leeds,
UK
2Department of Health
Sciences and The Hull York
Medical School, University of
York, York, UK
3Medicines and Healthcare
Products Regulatory Agency,
London, UK
Correspondence to
Dr Rebecca Dickinson;
[email protected]
ABSTRACT
Objective: To explore the impact of providing
additional information about the potential benefits
of simvastatin in a patient leaflet on attitudes and
beliefs.
Design: Interview-based study using a generic
qualitative approach and framework analysis.
Participants: 21 participants receiving a prescription
for simvastatin were recruited from a general
practitioner practice (from a total of 120). 8
participants were women; the age range was 55–92.
Intervention: Participants were provided with leaflets
showing one of 3 types of additional benefit
information: (1) textual statement, (2) number
needed to treat (NNT) or (3) natural frequency.
Semistructured interviews explored patient’s attitudes
and beliefs.
Results: A descriptive narrative of preferences for
format suggested patients prefer textual as opposed to
numerical benefit information. Significant barriers to
the acceptance of numerical benefit information
included difficulty in understanding the numbers.
Patients overestimated the benefits of statins and
expressed surprise at the numerical information.
Conclusions: Textual information was preferred but
numerical information, in particular in the form of a
natural frequency, may help patients make judgements
about their medicines. NNTs were found to be very
difficult to understand. This raises the prospect that
some patients might reject medicines because of
disappointment with the perceived low benefits of their
medicines. The self-reported impact on behaviour
appeared minimal with reports of intentions to ‘do
what the doctor tells me’. Further research is needed to
explore the impact of such statements on people who
are yet to be prescribed a statin.
INTRODUCTION
For patients to take their medicines safely
and effectively, it is important that they
receive good quality information about their
treatments. Across the European Union, all
licensed medicines are required to be pro-
vided with written medicines information ...
This document provides an overview of the management of dyslipidemia. It discusses lipoprotein classification and composition. It also outlines the non-pharmacological and pharmacological treatment approaches for different dyslipidemia scenarios, including various drug classes like statins, PCSK9 inhibitors, fibrates and their effects. It discusses treatment approaches for different patient groups such as those with cardiovascular disease, diabetes, chronic kidney disease, inflammatory conditions and others. The guidelines for screening and management of dyslipidemia in various clinical situations are summarized.
The document discusses the benefits of angiotensin receptor blockers (ARBs) in treating chronic kidney disease, specifically in patients with type 2 diabetes. It summarizes the results of the RENAAL clinical trial which found that losartan reduced the risk of doubling of serum creatinine, end-stage renal disease, and other kidney-related outcomes in patients with type 2 diabetes and nephropathy by 16-28% compared to placebo. The trial demonstrated that losartan provided renoprotective effects beyond blood pressure control alone in this high-risk population.
Javed Butler, MD, MPH, MBA, discusses heart failure in this CME activity titled, "New Frontiers in Managing Heart Failure: Are SGLT2 Inhibitors the Next Leap Forward in Optimizing Patient Care?" For the full presentation, downloadable infographics, monograph, complete CME information, and to apply for credit, please visit us at http://bit.ly/2JG2v9l. CME credit will be available until May 29, 2020.
Cardio-Renal Protection Through Renin–Angiotensin–Aldosterone System Inhibitionmagdy elmasry
Physiological and detrimental roles of RAAS molecules in cardiac, vascular tissues and kidneys.‘cardiovascular continuum’ Barriers In Optimizing RAAS Inhibition.The effects of angiotensin II inhibition and improvement in bradykinin availability
Role of raas inhibition in management of hypertensionKyaw Win
1) RAAS inhibition plays a central role in the pathogenesis of cardiovascular disease by modulating processes like vasoconstriction, inflammation, endothelial dysfunction, and atherosclerosis.
2) Both ACE inhibitors and ARBs have been shown to reduce target organ damage and improve endothelial function through various mechanisms such as increasing NO and reducing oxidative stress and inflammation.
3) Clinical trials provide evidence that RAAS inhibition can reduce atherosclerosis progression, cardiac hypertrophy, and events in conditions like coronary artery disease and heart failure.
Hypertension: New Concepts, Guidelines, and Clinical Management Hypertensio...MedicineAndFamily
This document summarizes guidelines for diagnosing and treating hypertension. It discusses the prevalence of hypertension and cardiovascular disease in the US population. It reviews risk factors for hypertension and cardiovascular events. It also summarizes findings from clinical trials demonstrating the benefits of treating hypertension, including reduced risks of stroke, heart failure, and myocardial infarction. Thiazide diuretics are recommended as first-line treatment based on their effectiveness and lower costs.
Effects of Sodium Glucose contransporter (SGLT2) inhibition on renal outcomes in patients with (diabetic) chronic kidney disease.
Presentation given during the East by Southwest, Annual Update in Nephrology, September 17th 2017, Santa Fe, NM
http://medicine.unm.edu/academic-divisions/nephrology/east-by-southwest.html
1) Statins are highly effective in reducing LDL-C and cardiovascular risk, playing a cornerstone role in lipid management. They work by inhibiting HMG-CoA reductase.
2) Atorvastatin has been extensively studied in large trials and shown to significantly reduce major cardiovascular events when doses are increased from 10 mg to 80 mg.
3) Studies in India found that high dose atorvastatin (80 mg) was well tolerated and more effective at reducing LDL-C and hs-CRP than lower doses in ACS patients. However, many ACS patients in India were not receiving statins as recommended.
- Bisoprolol is a highly selective beta-1 blocker used to treat heart failure, hypertension, and myocardial infarction.
- Studies show bisoprolol lowers blood pressure and heart rate more effectively than atenolol, with greater reductions throughout the day.
- The CIBIS II trial found adding bisoprolol to standard heart failure treatment reduced all-cause mortality by 34% and reduced hospitalizations compared to placebo.
Efonidipine is a calcium channel blocker that uniquely blocks L-type, N-type, and T-type calcium channels. It has potent antihypertensive effects and provides cardiovascular protection through multiple mechanisms. These include reducing myocardial oxygen demand, improving endothelial function, attenuating platelet activation, and inhibiting aldosterone levels. Efonidipine also has protective effects on the kidneys, brain, and metabolic function. It has an excellent safety profile with minimal side effects like pedal edema compared to other calcium channel blockers.
This document discusses hypertension in patients with chronic kidney disease. It begins by noting that hypertension and diabetes are leading causes of end-stage renal disease. It then discusses how poorly controlled hypertension can cause or accelerate renal failure. The document provides an overview of diseases attributable to hypertension and outlines the paradigm shift in hypertension therapy to focus on more than just lowering blood pressure. It also discusses lifestyle modifications, target organ damage, left ventricular hypertrophy, dipping patterns, morbidity and mortality related to hypertension, and approaches to hypertension treatment and management.
Vymada Tablet (ARNI: Angiotensin Receptor Neprilysin Inhibitor) is an anti-hypertensive drug used in combination with Sacubitril & Valsartan to reduce the risk of cardiovascular events in patients with chronic heart failure (NYHA Class II-IV) and reduced ejection fraction.
The document summarizes guidelines from the International Society of Hypertension (ISH), World Health Organization (WHO), American College of Cardiology/American Heart Association (ACC/AHA), and European Society of Cardiology/European Society of Hypertension (ESC/ESH) on the diagnosis and treatment of hypertension. It compares the guidelines on prevalence of hypertension, treatment thresholds and targets, drug choice and sequencing, and targets for specific patient groups. While the guidelines have some differences, they also have many similarities, including treatment targets of under 140/90 mmHg for most patients and under 130/80 mmHg for high-risk groups.
Dapagliflozin is an SGLT2 inhibitor that has shown benefits in managing type 2 diabetes and reducing cardiovascular outcomes. The document summarizes results from several key studies on dapagliflozin. The DECLARE-TIMI trial showed that dapagliflozin reduced the risk of cardiovascular death or hospitalization for heart failure compared to placebo in patients with type 2 diabetes with high cardiovascular risk. The DAPA-HF trial found that dapagliflozin reduced the risks of worsening heart failure or cardiovascular death compared to placebo in patients with heart failure regardless of diabetes status. Dapagliflozin also improved outcomes related to heart failure in the DEFINE-HF trial.
Recent advances in treatment of Hypertension -- Drugs inhibiting RAAS, Diuret...Deepthivagge
This document summarizes guidelines for diagnosing hypertension, mechanisms of action for antihypertensive drug classes, and clinical trials of new antihypertensive drugs. The JNC 7 criteria classify blood pressure and define thresholds for normal, prehypertension, and stages 1 and 2 of hypertension. Drugs that inhibit the renin-angiotensin-aldosterone system lower blood pressure by blocking counter-regulatory mechanisms. New direct renin inhibitors and their mechanisms of action are discussed along with clinical trial results comparing their efficacy to ACE inhibitors and ARBs. Calcium channel blockers mechanisms and advantages are also summarized, along with current uses and new drugs in clinical trials.
This document discusses several clinical studies that compare the effects of different statin drugs on cardiovascular outcomes and the progression of atherosclerosis. The STELLAR study showed that rosuvastatin more effectively lowered LDL-C and raised HDL-C than other statins. Two real-world studies found that rosuvastatin use was associated with a 28-40% lower risk of cardiovascular events compared to other statins. The METEOR study found that rosuvastatin slowed the progression of atherosclerosis whereas the ENHANCE study found that ezetimibe added to simvastatin provided no benefit.
This document provides an overview of canagliflozin, an SGLT2 inhibitor used to treat type 2 diabetes. It discusses the pathogenesis of type 2 diabetes, progressive beta cell dysfunction, and the kidney's role in glucose regulation. It then reviews canagliflozin's mechanism of action as an SGLT2 inhibitor, increasing urinary glucose excretion and reducing blood glucose levels. The document summarizes canagliflozin's clinical trials, pharmacokinetics, efficacy, safety profile, and effects on renal function and lipids.
What’s new in Lipidology, Lessons from “recent guidelines“Arindam Pande
1. The 2018 ACC/AHA cholesterol guidelines provide 10 key take-home messages focusing on lifestyle management, statin therapy for various risk groups, and risk assessment approaches.
2. The guidelines emphasize lifestyle therapy and statins for secondary prevention, with an LDL-C goal of 70 mg/dL for very high risk patients to consider adding nonstatins.
3. They provide guidance on statin use for various primary prevention groups based on risk levels and discussion, including an expanded definition of intermediate risk factors.
1) The SPRINT trial was a randomized controlled trial that compared an intensive blood pressure treatment target of less than 120 mmHg to a standard target of less than 140 mmHg. 9,361 participants aged 50 and older with high cardiovascular risk were enrolled and followed for a median of 3.26 years.
2) The primary outcome was a composite of myocardial infarction, other acute coronary syndromes, stroke, heart failure, or death from cardiovascular causes. Key secondary outcomes included all-cause mortality and renal outcomes.
3) Results found that the intensive treatment target reduced the primary composite outcome by 25% and all-cause mortality by 27%, showing benefit of the lower blood pressure target. The trial was stopped early due
Nejm Effects of Aspirin for Primary Prevention in Persons with Diabetes MellitusBhargav Kiran
This document summarizes the results of the ASCEND trial, which investigated the effects of low-dose aspirin (100 mg daily) for primary prevention of cardiovascular events in 15,480 adults with diabetes but no history of cardiovascular disease. Over a mean follow-up of 7.4 years:
- Serious vascular events were lower in the aspirin group (8.5%) compared to placebo (9.6%), but major bleeding events were higher with aspirin (4.1% vs 3.2%).
- There was no significant difference in gastrointestinal cancer rates between groups.
- Aspirin prevented some vascular events but increased bleeding, largely offsetting the benefits. The absolute risks and benefits were closely balanced
Providing additional information aboutthe benefits of statin.docxwoodruffeloisa
Providing additional information about
the benefits of statins in a leaflet for
patients with coronary heart disease:
a qualitative study of the impact on
attitudes and beliefs
Rebecca Dickinson,
1
David K Raynor,
1
Peter Knapp,
2
Jan MacDonald
3
To cite: Dickinson R,
Raynor DK, Knapp P, et al.
Providing additional
information about the
benefits of statins in a leaflet
for patients with coronary
heart disease: a qualitative
study of the impact on
attitudes and beliefs. BMJ
Open 2016;6:e012000.
doi:10.1136/bmjopen-2016-
012000
▸ Prepublication history and
additional material is
available. To view please visit
the journal (http://dx.doi.org/
10.1136/bmjopen-2016-
012000).
Received 22 March 2016
Revised 3 November 2016
Accepted 8 November 2016
1School of Healthcare,
University of Leeds, Leeds,
UK
2Department of Health
Sciences and The Hull York
Medical School, University of
York, York, UK
3Medicines and Healthcare
Products Regulatory Agency,
London, UK
Correspondence to
Dr Rebecca Dickinson;
[email protected]
ABSTRACT
Objective: To explore the impact of providing
additional information about the potential benefits
of simvastatin in a patient leaflet on attitudes and
beliefs.
Design: Interview-based study using a generic
qualitative approach and framework analysis.
Participants: 21 participants receiving a prescription
for simvastatin were recruited from a general
practitioner practice (from a total of 120). 8
participants were women; the age range was 55–92.
Intervention: Participants were provided with leaflets
showing one of 3 types of additional benefit
information: (1) textual statement, (2) number
needed to treat (NNT) or (3) natural frequency.
Semistructured interviews explored patient’s attitudes
and beliefs.
Results: A descriptive narrative of preferences for
format suggested patients prefer textual as opposed to
numerical benefit information. Significant barriers to
the acceptance of numerical benefit information
included difficulty in understanding the numbers.
Patients overestimated the benefits of statins and
expressed surprise at the numerical information.
Conclusions: Textual information was preferred but
numerical information, in particular in the form of a
natural frequency, may help patients make judgements
about their medicines. NNTs were found to be very
difficult to understand. This raises the prospect that
some patients might reject medicines because of
disappointment with the perceived low benefits of their
medicines. The self-reported impact on behaviour
appeared minimal with reports of intentions to ‘do
what the doctor tells me’. Further research is needed to
explore the impact of such statements on people who
are yet to be prescribed a statin.
INTRODUCTION
For patients to take their medicines safely
and effectively, it is important that they
receive good quality information about their
treatments. Across the European Union, all
licensed medicines are required to be pro-
vided with written medicines information ...
Inter society consensus for the management of peripheral arterial disease (tasc)Jonathan Campos
This document summarizes the key findings of the Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). It discusses the prevalence of peripheral arterial disease (PAD), finding that PAD affects approximately 3-10% of the general population but is asymptomatic in around 75% of cases. The ratio of asymptomatic to symptomatic PAD is estimated to be between 3:1 and 4:1. Symptomatic PAD presents mainly as intermittent claudication. The document also outlines the grading system used to rate the strength of recommendations.
This meta-analysis reviewed 15 randomized controlled trials involving over 188,000 participants to determine the effect of antioxidant vitamin supplementation on cardiovascular outcomes. The trials assessed supplements containing vitamin E, beta-carotene, and/or vitamin C compared to placebo. The analysis found that antioxidant vitamin supplementation had no significant effect on major cardiovascular events, myocardial infarction, stroke, total death, cardiac death, or other outcomes. There was no evidence that antioxidant vitamin supplements provide cardiovascular benefits.
You will write the literature review for your research proposal th.docxrosemarybdodson23141
This document provides instructions for writing a literature review for a research proposal. It states that the literature review should summarize and synthesize the key findings from 8 research articles on the topic. The review should combine results from both qualitative and quantitative studies, rather than summarizing each article separately. It must include the 4 articles from previous weeks, as well as additional relevant sources. An example is provided.
Proton Pump Inhibitors and Risk of Acute and Chronic Kidney Disease: A Retros...KhalafAlGhamdi
This document summarizes a study presented at a nephrology journal club that examined the association between proton pump inhibitor (PPI) use and the risk of acute kidney injury (AKI) and chronic kidney disease (CKD) using a large health insurance database. The study found that PPI use was associated with a 4-fold higher risk of AKI and a 20% higher risk of CKD compared to non-users. While the results strengthen evidence of this association, limitations include potential residual confounding and inability to account for over-the-counter medication use. The conclusion calls for provider education and deprescribing initiatives to reduce PPI overuse and potential kidney risks.
Parental alcohol consumption and the risk of congenital heart diseases in off...BARRY STANLEY 2 fasd
Conclusions: Although the role of potential bias and evidence of heterogeneity should be carefully evaluated, our review indicates that parental alcohol exposures are significantly associated with the risk of CHDs in offspring, which highlights the necessity of improving health awareness to prevent alcohol exposure during preconception and conception periods.
This nested case-control study analyzed data from 8.9 million Ontario residents who had routine complete blood count (CBC) tests between 2007-2017 to evaluate the association between platelet count and cancer risk. The study found that an elevated platelet count was associated with increased odds of cancer diagnosis within 10 years of the CBC test. The odds were highest for cancers diagnosed within 6 months, and decreased with more time between the test and diagnosis. A very high platelet count was most strongly associated with colon, lung, ovarian and stomach cancers.
Prognosis of pulmonary arterial hypertensiongisa_legal
1) The expected survival of patients with pulmonary arterial hypertension (PAH) varies based on the underlying cause, with idiopathic PAH having a median survival of 2.8 years based on historical studies.
2) Medical therapies like epoprostenol have improved survival rates, with studies showing 1, 2, and 3 year survival rates with epoprostenol between 63-87%, compared to 27-52% historically.
3) The prognosis is worse for PAH associated with scleroderma or collagen vascular diseases, with median survival around 1-2 years, while PAH associated with congenital heart disease has a better prognosis, with reported 3 year survival of 77%.
This study compared the long-term (18-month) outcomes of supervised exercise (SE), stent revascularization (ST), and optimal medical therapy (OMT) for patients with claudication due to aortoiliac peripheral artery disease. 79 patients completed the 18-month follow-up assessment. The study found that both SE and ST resulted in significantly greater improvements in peak walking time and claudication onset time compared to OMT. SE and ST also provided durable improvements in quality of life measures up to 18 months. Both SE and ST had better long-term outcomes than OMT alone for treating claudication, demonstrating the durability of exercise interventions for peripheral artery disease.
Short Term Outcomes after Use of Intracardiac Bone Stem Cell Transplantation ...crimsonpublishersOJCHD
Short Term Outcomes after Use of Intracardiac Bone Stem Cell Transplantation for Management of Heart Failure: A Meta-Analysis by Rohit SL in Open Journal of Cardiology & Heart Diseases
The document analyzes and compares hospital data from Arizona in 2012 to national averages for the same year. It finds that Arizona's average length of stay and cost per discharge were slightly higher than national averages, while its cost per day was significantly higher. The top diagnoses in both Arizona and the US were related to childbirth and joint/digestive issues, though the US also had a high rate of psychoses diagnoses.
American Heart Association - Funding Vital New HeartJohn Kriak
The American Heart Association (AHA) funds critical cardiovascular health research as a foundational mission. Since 1949, the organization has invested more than $5.7 billion into new research, with ongoing AHA-funded projects numbering 1,700 and representing $479 million in allocated capital. In 2022-23 alone, the organization provided $178 million in funding toward 868 new projects.
Throughout its history, AHA has assisted in launching numerous careers in brain and cardiovascular research, including 15 scientists who achieved the Nobel prize. Over the past five years, the funding landscape has changed dramatically, with funding for scientists from underrepresented ethnic and racial groups more than doubling.
The impact of such funding in legitimizing research can be substantial, with each $1 of AHA early-career faculty development awards generating, on average, 7.8 dollars in additional funding. The volunteer resources required to arrange such financing levels are immense. In 2022-23, 2,234 peer review volunteers evaluated 3,775 funding proposals. Of these, 1,996 applications, representing $535 million in requested funds, did not receive support.
One of the major funding events each year centers on selecting three Merit Award winners, who receive $1 million each toward researching heart disease causes and treatments. Announced in January, the winners for 2024 spanned researchers in Pennsylvania, Massachusetts, and California.
A Stanford University School of Medicine professor, Dr. Philip S. Tsao, is researching the impact of vaping on abdominal aortic aneurysm (AAA) risks. AAA involves a weakening of a major artery in the abdomen, with its rupture often resulting in death. As the researcher describes it, around 90 percent of people who suffer from AAA have a tobacco history of use. Yet, this relationship has been little studied, and there is almost no data tracking e-cigarettes and vaping and the prevalence of such aneurysms.
Associated with the University of Pennsylvania School of Medicine, Dr. Daniel J. Rader studies large-scale human genetics as a pathway of altered lipid metabolism, which can result in heart disease. A focus is on new genes expressed in the liver, which modulate the blood lipids implicated in many forms of heart disease. The research aims to unlock core cellular and biological mechanisms contributing to cardiovascular disease risk.
Finally, Harvard Medical School professor Dr. Joseph Loscalzo is working on uncovering links between heart disease and naturally occurring chemicals in foods (or the foods themselves). Employing high-speed computers and algorithmic modeling, he has identified 135,000 such chemicals. A key focus is understanding how food chemicals interact with cellular proteins and which chemicals help protect the heart. This potentially lays a framework for developing new heart-protective drugs.
This study evaluated thyroid hormone replacement dosing in overweight and obese patients after thyroidectomy. The researchers found:
- After thyroidectomy, levothyroxine dosing is often based on body weight, but obese patients may need a lower dose relative to their weight.
- The study aimed to identify a better method for determining the initial levothyroxine dose for obese patients after thyroidectomy.
- The results suggest obese patients may require a levothyroxine dose lower than what is typically calculated based solely on their body weight. Accounting for body composition, like fat mass, may help determine a more appropriate starting dose.
Mangement of chronic heart failure 93432-rephrasedIrfan iftekhar
Cardiac resynchronization therapy significantly reduces morbidity and mortality in patients with heart failure. A randomized controlled trial found that cardiac resynchronization reduced the primary endpoint of death from any cause by 36% compared to medical therapy alone. Mortality was lower in the cardiac resynchronization group, demonstrating improved outcomes. While cardiac resynchronization is an effective treatment, its cost-effectiveness remains uncertain due to the therapy's expense. Further research is still needed to determine its overall value.
This expert consensus document from the World Heart Federation provides recommendations for antiplatelet therapy in East Asian patients with acute coronary syndrome or undergoing percutaneous coronary intervention. While current guidelines are based primarily on large Western clinical trials, few East Asian patients were included. Additionally, East Asians have differing risk profiles and responses to antiplatelet drugs compared to white patients. This consensus aims to determine the most appropriate antiplatelet strategies for East Asians based on available evidence.
Similar to Comparative effectiveness of acei and arbi (20)
A 57-year-old woman was admitted to the hospital with chest pain. Electrocardiograms and troponin levels were normal. Intravascular ultrasound was performed before placing a stent in the left main coronary artery and left anterior descending artery to treat a blockage. The minimum lumen area increased to 4.24mm x 4.13mm after stenting.
Congenital defects can put a strain on the heart, causing it to work harder. To stop your heart from getting weaker with this extra work, your doctor may try to treat you with medications. They are aimed at easing the burden on the heart muscle. You need to control your blood pressure if you have any type of heart problem.
Changing your lifestyle can help control and manage high blood pressure. Your health care provider may recommend that you make lifestyle changes including:
Eating a heart-healthy diet with less salt
Getting regular physical activity
Maintaining a healthy weight or losing weight
Limiting alcohol
Not smoking
Getting 7 to 9 hours of sleep daily
CRISPR technologies have progressed by leaps and bounds over the past decade, not only having a transformative effect on
biomedical research but also yielding new therapies that are poised to enter the clinic. In this review, I give an overview of (i)
the various CRISPR DNA-editing technologies, including standard nuclease gene editing, base editing, prime editing, and epigenome editing, (ii) their impact on cardiovascular basic science research, including animal models, human pluripotent stem
cell models, and functional screens, and (iii) emerging therapeutic applications for patients with cardiovascular diseases, focusing on the examples of Hypercholesterolemia, transthyretin amyloidosis, and Duchenne muscular dystrophy.
This case report describes a patient who underwent seven operations over one year to treat recurrent pacemaker pocket infections. The patient had undergone a splenectomy seven years prior due to a splenic rupture from a traffic accident. This left the patient immunocompromised and at higher risk for infection. The patient later required a pacemaker implantation for complete heart block. The pacemaker pocket developed repeated infections, likely due to the patient's asplenic state impairing immunity. The infections were difficult to treat due to multiple complicating factors, including an abandoned pacemaker lead and reuse of a sterilized pacemaker. This highlights the influence of patient factors like asplenia on procedural outcomes like pacemaker implantation.
Transcatheter closure of patent ductus arteriosus (PDA) is feasible in low-birth-weight infants. A female baby was born prematurely with a birth weight of 924 g. She had a PDA measuring 3.7 mm. She was dependent on positive pressure ventilation for congestive heart failure in addition to the heart failure medications. She could not be discharged from the hospital even after 79 days of birth, and even though her weight reached 1.9 kg in the neonatal intensive care unit. We attempted to plug the PDA using an Amplatzer Piccolo Occluder, but the device failed to anchor. Then, the PDA was plugged using a 4-6 Amplatzer Duct Occluder using a 6-Fr sheath which was challenging.
Accidental misplacement of the limb lead electrodes is a common cause of ECG abnormality and may simulate pathology such as ectopic atrial rhythm, chamber enlargement or myocardial ischaemia and infarction
A Case of Device Closure of an Eccentric Atrial Septal Defect Using a Large D...Ramachandra Barik
Device closure of an eccentric atrial septal defect can be challenging and needs technical modifications to avoid unnecessary complications. Here, we present a case of a 45-year-old woman who underwent device closure of an eccentric defect with a large device. The patient developed pericardial effusion and left-sided pleural effusion due to injury to the junction of right atrium and superior vena cava because of the malalignment of the delivery sheath and left atrial disc before the device was pulled across the eccentric defect despite releasing the left atrial disc in the left atrium in place of the left pulmonary vein. These two serious complications were managed conservatively with close monitoring of the case during and after the procedure.
1) Bradycardia can be caused by abnormalities in the conduction system or autonomic nervous system. The conduction system includes the sinus node, AV node, His-Purkinje system and different types of heart block can occur when impulses are blocked at different locations.
2) There are three main types of AV block - first degree, second degree (Mobitz types I and II), and third degree. High grade AV block involves blockage of two or more consecutive impulses.
3) Third degree or complete heart block results in complete dissociation between the atria and ventricles with independent pacemakers. It can occur at the AV node or below in the His-Purkin
1. Bradycardia is defined as a resting heart rate below 50 beats per minute. It can be physiological or pathological.
2. Sinus bradycardia originates from the sinus node and has a normal P wave morphology with a prolonged PR interval. It can be caused by increased vagal tone, medications, or hypothyroidism.
3. Sick sinus syndrome is characterized by sinus bradycardia, sinus arrest, or combinations of sinus node and AV node dysfunction. It may involve intermittent bradycardia and tachycardia. Pacemaker implantation is usually treatment.
This document discusses ventricular arrhythmias including their origins, characteristics, classifications, and causes. It provides details on:
- The sites of origin for supraventricular tachycardia (SVT) and ventricular arrhythmias.
- Characteristics that distinguish SVT from ventricular arrhythmias such as QRS width.
- Classifications of ventricular arrhythmias including premature ventricular complexes, ventricular tachycardia, fibrillation, and electrical storm.
- Causes and characteristics of different types of ventricular tachycardia such as monomorphic VT, polymorphic VT, and torsades de pointes.
- Investigations and treatments for ventricular arrhythmias including cardiac imaging
This document provides information on supraventricular tachycardia (SVT), including:
- The anatomy and conduction system of the heart that is relevant to SVT.
- The mechanisms that can cause cardiac arrhythmias, including disorders of impulse formation, conduction, and combinations of the two.
- Characteristics used to classify different types of arrhythmias based on rate, rhythm, site of origin, and QRS morphology.
- Specific types of SVT like atrial fibrillation, AV nodal reentry tachycardia, and accessory pathway mediated tachycardias.
- Methods for diagnosing and treating SVT such as electrophysiology studies, catheter ablation
Trio of Rheumatic Mitral Stenosis, Right Posterior Septal Accessory Pathway a...Ramachandra Barik
A 57-year-old male presented with recurrent palpitations. He was diagnosed with rheumatic mitral stenosis, right posterior septal accessory pathway and atrial flutter. An electrophysiological study after percutaneous balloon mitral valvotomy showed that the palpitations were due to atrial flutter with right bundle branch aberrancy. The right posterior septal pathway was a bystander because it had a higher refractory period than the atrioventricular node.
This document discusses anticoagulation therapy options during pregnancy for different cardiac conditions. It notes that vitamin K antagonists (VKAs) should be avoided in the first trimester due to risk of embryopathy but can be used in the second and third trimester with risks of 0.7-2% of foetopathy. Unfractionated heparin does not cross the placenta but its use throughout pregnancy is not recommended due to risk of foetopathy. Low molecular weight heparin is considered the safest option for anticoagulation in weeks 6-12 when risk of embryopathy is a concern and has not been associated with risk of foetopathy. Fondaparinux use should be limited
Percutaneous balloon dilatation, first described by
Andreas Gruentzig in 1979, was initially performed
without the use of guidewires.1 The prototype
balloon catheter was developed as a double lumen
catheter (one lumen for pressure monitoring or
distal perfusion, the other lumen for balloon inflation/deflation) with a short fixed and atraumatic
guidewire at the tip. Indeed, initially the technique
involved advancing a rather rigid balloon catheter
freely without much torque control into a coronary
artery. Bends, tortuosities, angulations, bifurcations,
and eccentric lesions could hardly, if at all, be negotiated, resulting in a rather frustrating low procedural success rate whenever the initial limited
indications (proximal, short, concentric, noncalcified) were negated.2 Luck was almost as
important as expertise, not only for the operator,
but also for the patient. It is to the merit of
Simpson who, in 1982, introduced the novelty of
advancing the balloon catheter over a removable
guidewire, which had first been advanced in the
target vessel.3 This major technical improvement
resulted overnight in a notable increase in the procedural success rate. Guidewires have since evolved
into very sophisticated devices.
Optical coherence tomography-guided algorithm for percutaneous coronary intervention. Vessel diameter should be assessed using the external elastic lamina (EEL)-EEL diameter at the reference segments, and rounded down to select interventional devices (balloons, stents). If the EEL cannot be identified, luminal measures are used and rounded up to 0.5 mm larger for selection of the devices. Optical coherence tomography (OCT)-guided optimisation strategies post stent implantation per EEL-based diameter measurement and per lumen-based diameter measurement are shown. For instance, if the distal EEL-EEL diameter measures 3.2 mm×3.1 mm (i.e., the mean EEL-based diameter is 3.15 mm), this number is rounded down to the next available stent size and post-dilation balloon to be used at the distal segment. Thus, a 3.0 mm stent and non-compliant balloon diameter is selected. If the proximal EEL cannot be visualised, the mean lumen diameter should be used for device sizing. For instance, if the mean proximal lumen diameter measures 3.4 mm, this number is rounded up to the next available balloon diameter (within up to 0.5 mm larger) for post-dilation. MLA: minimal lumen area; MSA: minimal stent area;NC: non-compliant
Brugada syndrome (BrS) is an inherited cardiac disorder,
characterised by a typical ECG pattern and an increased
risk of arrhythmias and sudden cardiac death (SCD).
BrS is a challenging entity, in regard to diagnosis as
well as arrhythmia risk prediction and management.
Nowadays, asymptomatic patients represent the majority
of newly diagnosed patients with BrS, and its incidence
is expected to rise due to (genetic) family screening.
Progress in our understanding of the genetic and
molecular pathophysiology is limited by the absence
of a true gold standard, with consensus on its clinical
definition changing over time. Nevertheless, novel
insights continue to arise from detailed and in-depth
studies, including the complex genetic and molecular
basis. This includes the increasingly recognised
relevance of an underlying structural substrate. Risk
stratification in patients with BrS remains challenging,
particularly in those who are asymptomatic, but recent
studies have demonstrated the potential usefulness
of risk scores to identify patients at high risk of
arrhythmia and SCD. Development and validation of
a model that incorporates clinical and genetic factors,
comorbidities, age and gender, and environmental
aspects may facilitate improved prediction of disease
expressivity and arrhythmia/SCD risk, and potentially
guide patient management and therapy. This review
provides an update of the diagnosis, pathophysiology
and management of BrS, and discusses its future
perspectives.
The Human Developmental Cell Atlas (HDCA) initiative, which is part of the Human Cell Atlas, aims to create a comprehensive reference map of cells during development. This will be critical to understanding normal organogenesis, the effect of mutations, environmental factors and infectious agents on human development, congenital and childhood disorders, and the cellular basis of ageing, cancer and regenerative medicine. Here we outline the HDCA initiative and the challenges of mapping and modelling human development using state-of-the-art technologies to create a reference atlas across gestation. Similar to the Human Genome Project, the HDCA will integrate the output from a growing community of scientists who are mapping human development into a unified atlas. We describe the early milestones that have been achieved and the use of human stem-cell-derived cultures, organoids and animal models to inform the HDCA, especially for prenatal tissues that are hard to acquire. Finally, we provide a roadmap towards a complete atlas of human development.
The treatment of patients with advanced acute heart failure is still challenging.
Intra-aortic balloon pump (IABP) has widely been used in the management of
patients with cardiogenic shock. However, according to international guidelines, its
routinary use in patients with cardiogenic shock is not recommended. This recommendation is derived from the results of the IABP-SHOCK II trial, which demonstrated
that IABP does not reduce all-cause mortality in patients with acute myocardial infarction and cardiogenic shock. The present position paper, released by the Italian
Association of Hospital Cardiologists, reviews the available data derived from clinical
studies. It also provides practical recommendations for the optimal use of IABP in
the treatment of cardiogenic shock and advanced acute heart failure.
Left ventricular false tendons (LVFTs) are fibromuscular
structures, connecting the left ventricular
free wall or papillary muscle and the ventricular
septum.
There is some discussion about safety issues during
intense exercise in athletes with LVFTs, as these
bands have been associated with ventricular arrhythmias
and abnormal cardiac remodelling. However,
presence of LVFTs appears to be much more common
than previously noted as imaging techniques
have improved and the association between LVFTs
and abnormal remodelling could very well be explained
by better visibility in a dilated left ventricular
lumen.
Although LVFTsmay result in electrocardiographic abnormalities
and could form a substrate for ventricular
arrhythmias, it should be considered as a normal
anatomic variant. Persons with LVFTs do not appear
to have increased risk for ventricular arrhythmias or
sudden cardiac death.
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Kat...rightmanforbloodline
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
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Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptxHolistified Wellness
We’re talking about Vedic Meditation, a form of meditation that has been around for at least 5,000 years. Back then, the people who lived in the Indus Valley, now known as India and Pakistan, practised meditation as a fundamental part of daily life. This knowledge that has given us yoga and Ayurveda, was known as Veda, hence the name Vedic. And though there are some written records, the practice has been passed down verbally from generation to generation.
share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
• Pitfalls and pivots needed to use AI effectively in public health
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Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
2. Open Heart
2 Ko D, et al. Open Heart 2019;6:e001010. doi:10.1136/openhrt-2019-001010
studies have even concluded that ARBs are not signifi-
cantly different compared with placebo.8 9 11
One of the difficulties in comparing the safety and
effectiveness of ACEIs relative to ARBs is the paucity of
head-to-head clinical trials. In fact, only three large trials
have directly compared ACEIs and ARBs in patients
with coronary artery disease.12–14
Of these trials, two
enrolled patients had acute MI complicated with heart
failure,12 13
and the other enrolled patients were at high
risk of vascular events.14
Moreover, two of these trials were
conducted close to two decades ago.12 13
It is difficult to
know whether the results of these older trials are still
applicable in contemporary clinical practice. Given that
ACEIs and ARBs are commonly prescribed in the treat-
ment of patients with cardiovascular disease, we sought
to address this gap in knowledge by comparing the real-
world effectiveness of ACEIs and ARBs in a large popula-
tion-based cohort with prior MI using longitudinal linked
databases in Ontario, Canada.
Methods
Design and data sources
We conducted a retrospective cohort study using popu-
lation-based databases in Ontario, Canada. The Cardi-
ovascular Health in Ambulatory Care Research Team
(CANHEART) cohort was created by merging 17 different
longitudinal individual-level data sources.15
The data
sources used for this study have been described previously
with additional information on our study website (www.
canheart.ca).15–19
Primary databases that were used for this
study include (1) Ontario Health Insurance Plan, a registry
of all physician billings in Ontario; (2) Ontario Drug
Benefit, a registry of outpatient prescriptions; (3) Regis-
tered Persons Database of Ontario, a registry of the demo-
graphics of Ontario residents; (4) Canadian Institute for
Health Information (CIHI) Discharge Abstract Database, a
database used to identify prior cardiac risk factors, comor-
bidities and hospitalisations; (5) Statistics Canada census
data were used for neighbourhood income data; and (6)
Office of the Registrar General Deaths database was used to
ascertain cause of death. These datasets were linked using
unique encoded identifiers and analysed at the Institute for
Clinical Evaluative Sciences.
Study sample
Ontario residents who were alive on 1 April 2012 (index
date), older than 65 years and had a valid health insur-
ance number were eligible for inclusion in the study
cohort. Patients who were prescribed an ACEI or an ARB
in the 100 days before 1 April 2012 were considered for
inclusion. An age limit was used in our study because the
Ontario Drug Benefit database includes only prescription
drug information for those aged 65 years and above. The
cohort was defined as those who had a hospitalisation for
MI in the 10 years prior to the index date using Inter-
national Classification of Disease 10th version codes I21
and I22.
ACEIs and ARBs
ACEIs and ARBs that were available on the Ontario drug
formulary within 100 days of the index date were included
in the study. ACEIs included were benazepril, captopril,
cilazapril, enalapril, fosinopril, lisinopril, perindopril,
quinapril, ramipril and trandolapril. The ARB group
included candesartan, eprosartan, irbesartan, losartan,
olmesartan, telmisartan and valsartan. Different formu-
lations (eg, enalapril maleate and enalapril sodium) and
manufacturers (ie, brand and generic) were grouped
together, while intravenous drugs were excluded. Combi-
nation drugs were treated as ACEIs or ARBs, depending
on the respective formulation.
Outcomes
The primary outcome of this study was a composite of
cardiovascular mortality, hospitalisation for MI and
unstable angina at 3 years. We also examined this
composite outcome at 1 year. Secondary outcomes
included hospitalisation for MI or angina, and hospital-
isation for heart failure at 1 and 3 years. Cardiovascular
mortality was ascertained by the Office of the Registrar
General Deaths database. Hospitalisation for cardiac
conditions was ascertained by CIHI discharge abstract
database.
Statistical analysis
Demographic and clinical characteristics of patients
prescribed ACEIs and ARBs were compared using χ2
tests for categorical variables and the Wilcoxon rank-sum
test for continuous variables. To adjust for potential
confounding between the treatment groups, we used
the inverse probability of treatment weighting using
the propensity score to account for observed systematic
differences in baseline covariates between treatment
groups.20 21
The propensity score, which was defined as
the probability of receiving ACEIs, was estimated using
a logistic regression model in which treatment group
(ACEI vs ARB) was regressed on the following charac-
teristics related to the likelihood of being prescribed
one of the drugs: demographics (age, sex, income, rural
residency), timing of MI from index data, cardiac risk
factors (hypertension, diabetes, hyperlipidemia), cardi-
ovascular conditions (atrial arrhythmia, cerebrovascular
disease, heart failure, peripheral vascular disease, shock)
and medical comorbidities (anaemia, cancer, chronic
obstructive pulmonary disease, liver disease, peptic ulcer
disease, renal disease), cardiac procedures (cardiac cathe-
terisation, percutaneous coronary intervention, coronary
arterial bypass grafting) and prior medication (statins,
beta blockers, diuretics, clopidogrel, calcium channel
blockers, long-acting nitrates, warfarin).
Patients were then weighted by the inverse of the prob-
ability of receiving the treatment that they received.20
Balance of baseline covariates between the treatment
groups in the weighted cohort was assessed by computing
weighted standardised differences, with differences of less
than 0.1 indicating good balance.22
The effect of ACEIs
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Cardiac risk factors and prevention
Figure 1 Creation of the study cohort using the entire
Ontario population aged 65 to 105 years who were alive
on 1 April 2012. A total of 59 353 patients were included in
our study cohort after inclusion and exclusion criteria were
applied. ACEI, ACE inhibitor; ARB, angiotensin receptor
blocker
on the hazard of clinical outcomes was estimated using a
cause-specific proportional hazards model in which the
hazard of the outcome was regressed on the receipt of
ARBs as the reference. These models accounted for the
competing risk of non-cardiovascular death. The inverse
probability treatment weights were incorporated and a
robust variance estimator was used.23
We also compared
ACEIs and ARBs in the following predefined subgroups:
age (75, ≥75 years), sex (male, female), prior diabetes,
and prior heart failure for the composite outcome of
cardiovascular mortality, MI or unstable angina at 3 years.
This was achieved by examining the interaction between
treatment status and the subgroup variables of interest
within the propensity-weighted cohort.
Statistical analyses were conducted using SAS V.9.3
(SAS Institute, Cary, North Carolina, USA). A two-sided p
value of 0.05 was considered statistically significant. The
use of data in this project was authorised under section
45 of Ontario’s Personal Health Information Protection
Act, which does not require review by a Research Ethics
Board.
Results
Creation of the study cohort
Among the 2 166 144 individuals who were between the
ages of 65 and 105 years on 1 April 2012, 90 543 patients
had been hospitalised with an MI in the past 10 years
(figure 1). After excluding 30 095 patients who were
not prescribed an ACEI or an ARB, and 1095 patients
who were prescribed both concurrently, our final cohort
included 59 353 patients; 42 126 (71.0%) were prescribed
an ACEI and 17 227 (29.0%) were prescribed an ARB.
The most commonly prescribed ACEI in our cohort
in descending order was ramipril (67.2%), perindo-
pril (21.8%), lisinopril (3.1%), enalapril (2.9%) and
quinapril (1.9%), while the most commonly prescribed
ARBs were candesartan (25.6%), valsartan (23.2%),
irbesartan (18.9%), telmisartan (17.3%) and losartan
(12.4%) (online supplementary table 1).
Characteristics before and after propensity weighting
Prior to propensity score weighting, patients prescribed
ARBs were slightly older (77.4 years vs 76.9 years), had
higher rates of cardiac risk factors, including diabetes
(49.2% vs 43.9%), hypertension (94.7% vs 88.6%),
dyslipidemia (58.6% vs 55.3%) and renal disease (11.3%
vs 8.3%), and higher Charlson score compared with those
prescribed ACEIs (online supplementary table 2).
After propensity score weighting, the ACEI and the ARB
group were well balanced, with the standardised differ-
ences being less than 0.1 for all characteristics (table 1).
In the weighted sample, the mean age was 77, 59.5% of
patients were men, 45.6% had diabetes, 90.4% had hyper-
tension, 56.3% had dyslipidemia, 9.3% had renal disease
and 26.2% had a history of heart failure. The majority
of patients with MI patients were also prescribed statins
(84.1%) and beta blockers (70.3%).
Clinical outcomes of ACEIs versus ARBs
At 1 year, the primary outcome of cardiovascular death
or hospitalisation for MI or unstable angina occurred in
6.5% of patients in those taking ACEI and 5.7% in those
taking ARB (HR 1.14; 95% CI 1.05 to 1.23; p=0.001)
(table 2). This trend persisted at 3 years, with the primary
outcome occurring in 16.0% of those taking ACEI and
15.1% of those taking ARB (HR 1.07; 95% CI 1.02 to
1.12; p=0.008). The corresponding Kaplan-Meier curve
is shown in figure 2. The rate of cardiovascular death was
significant higher in the ACEI group compared with the
ARB group (table 2). At 1 year, cardiovascular death was
3.7% in the ACEI group and 2.8% in the ARB group (HR
1.31; 95% CI 1.18 to 1.45; p0.001). At 3 years, cardiovas-
cular death occurred in 9.9% of the ACEI group and in
8.6% of the ARB group (HR 1.16; 95% CI 1.09 to 1.23;
p0.001). We also observed lower all-cause mortality in
the ARB group at 6.6% at 1 year (vs 8.2% in the ACEI
group) and at 3 years (20.0% in the ARB group vs 22.4%
in the ACEI group). There was no significant difference
observed in hospitalisation for MI or angina, or heart
failure at 1 or 3 years.
Subgroup analyses
We performed subgroup analyses to investigate the
potential difference in clinical outcomes between ACEIs
and ARBs among predefined subgroups (table 3).
Subgroup analyses based on age, diabetes status and
prior heart failure did not show any significant interac-
tion. In contrast, a significant sex difference was observed
in which women had a higher HR associated with ACEIs
(1.17; 95% CI 1.10 to 1.26), while there was no significant
difference between the treatment groups among men
(HR 1.00; 95% CI 0.93 to 1.06, p0.001 for interaction).
To explore this potential discrepancy, we further explored
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Table 1 Baseline characteristics after propensity score
weighting
Characteristics
ACEIs
(%)
ARBs
(%)
Standardised
difference
Age (years), mean±SD 77.0±9.5 77.1±14.3 0.008
Men 59.6 59.5 0.002
Rural resident 15.7 15.7 0.001
Timing of MI in months,
mean±SD
53.7±42.5 54.0±65.0 0.008
Cardiovascular
comorbidities
Chronic ischaemic
heart disease
82.5 82.1 0.011
Angina 24.6 26.2 0.037
Atrial fibrillation/flutter 22.2 22.4 0.005
Diabetes 45.5 45.6 0.003
Heart failure 26.1 26.5 0.008
Hypertension 90.4 90.4 0.001
Dyslipidemia 56.3 56.2 0.001
Peripheral vascular
disease
7.1 7.2 0.002
Cerebrovascular
disease
9.4 9.4 0.001
Stroke/transient
ischaemic attack
7.7 7.7 0.001
Shock 5.0 4.9 0.002
Medical comorbidities
Renal disease 9.2 9.3 0.004
Cancer 11.1 11.1 0.001
Chronic obstructive
pulmonary disease
13.3 13.3 0.001
Liver disease 1.0 1.0 0.001
Peptic ulcer disease 4.0 4.0 0.001
Anaemia/blood disease 22.1 22.4 0.006
Charlson score, mean±SD 2.9±2.4 2.9±3.6 0.006
Prior cardiac invasive
procedures
Percutaneous coronary
intervention
46.8 46.5 0.006
Coronary artery bypass
grafting
20.4 20.5 0.002
Coronary
catheterisation
80.7 80.4 0.005
Medication use
Statins 84.0 84.1 0.001
Beta blocker 70.3 70.3 0.001
Diuretics 43.8 43.8 0.001
Clopidogrel 31.4 31.1 0.006
Calcium channel
blockers
30.5 30.5 0.001
Continued
Characteristics
ACEIs
(%)
ARBs
(%)
Standardised
difference
Nitrates 19.2 19.4 0.005
Warfarin 12.3 12.4 0.003
Spiroloactone 5.2 4.5 0.030
ACEI, ACE inhibitor; ARB, angiotensin receptor blocker; MI,
myocardial infarction.
Table 1 Continued
potential difference in dosages and medication adher-
ence by sex. The median dosage of ramipril in women
was 5 mg, while the median dosage was 7.5 mg in men. In
contrast, median dose of ARBs was identical between men
and women. Women appeared to have higher adherence
for ARBs than ACEIs. The proportional days covered for
ACEI was 74.9% in women and 77.4% in men, and 76.8%
for ARB in women and 75.9% in men.
Discussion
Using a population-based level big data cohort in
Ontario, Canada, we performed a comprehensive evalu-
ation comparing the clinical outcomes of ACEIs versus
ARBs in patients with prior MI. Despite the concern of
an ARB–MI paradox and that it may not be effective in
coronary artery disease, we found that ARBs were actually
associated with slightly lower rates of cardiovascular death
as compared with patients treated with ACEI. Heteroge-
neity in the treatment effects was seen in that women had
a significantly lower risk of events when prescribed ARBs
compared with ACEIs, while there was no difference in
the primary outcome between ACEI and ARB groups
for men. Our findings should help alleviate concerns
regarding the potential harmful effects associated with
ARBs.
It has been widely believed that ACEIs are more effective
than ARBs in a broad range of patients with cardiovascular
diseases.5 8
Practice guidelines have consistently recom-
mended using ARBs only when patients are not able to
tolerate the side effects associated with ACEIs.1 2
Recently,
Messerli and colleagues has challenged this conventional
wisdom.4
They pointed out that the relatively efficacy of
ACEIs and ARBs was mainly derived from comparisons
of trials that compared ACEIs versus placebo, and ARBs
versus placebo.4
Given the fact that trials of ACEIs were
conducted almost a decade before ARBs, the enrolled
patients were rarely treated with statin therapy or other
optimal medical therapy, and had almost twice the event
rates of patients enrolled in trials of ARBs. As a result, it is
very plausible that the temporal discrepancy in ACEI and
ARB trials may explain why ACEIs have previously been
shown to have larger benefits as compared with ARBs.3 4
Prior studies of ACEI versus ARBs in MI
Indeed, the three landmark trials that performed head-to-
head comparisons between ACEIs and ARBs—Valsartan
in Acute Myocardial Infarction (VALIANT), Optimal
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Cardiac risk factors and prevention
Table 2 Outcomes in the ACEI and ARB group
ACEI rate (%) ARB rate (%) ARB rate (%) Forest plot P value
1-year follow-up
CV death 3.7 2.8 1.31 (1.18–1.45)
0.001
CV death/hospitalisation for MI or angina 6.5 5.7 1.14 (1.05–1.23) 0.001
Hospitalisation for MI or angina 3.4 3.4 1.01 (0.92–1.12) 0.791
Hospitalisation for heart failure 3.3 3.2 1.03 (0.93–1.14) 0.541
3-year follow-up
CV death 9.9 8.6 1.16 (1.09–1.23) 0.001
CV death/hospitalisation for MI or angina 16.0 15.1 1.07 (1.02–1.12) 0.008
Hospitalisation for MI or angina 8.1 8.3 0.98 (0.92–1.05) 0.552
Hospitalisation for heart failure 8.2 8.2 1.00 (0.94–1.07) 0.984
0.5 1 HR 1.5
Favours ACEIs Favours ARBs
Higher HR indicates better outcomes associated with ARBs.
ACEI, ACE inhibitor; ARB, angiotensin receptor blocker; CV, cardiovascular; MI, myocardial infarction.
0.7
0.8
0.9
1.0
0 90 180 270 360 450 540 630 720 810 900 990 1080
Event-freesurvival
Time of follow-up in days
ACEI only
ARB only
Figure 2 Kaplan-Meier curve of the primary outcome in
patients prescribed ACE inhibitor (ACEI) and angiotensin
receptor blocker (ARB). Y-axis shows event rate rates and
x-axis shows time in days after assembling the study cohort.
Blue line depicts event rates for ACEI and red line depicts
event rates for ARBs.
Trial in Myocardial Infarction with the Angiotensin II
Antagonist Losartan (OPTIMAAL), and ongoing Telmis-
artan Alone and in Combination with Ramipril Global
Endpoint Trial (ONTARGET)—all showed no significant
outcome difference between patients prescribed ACEIs
and ARBs.12–14
While findings from our study may appear
be at odds with these trials, patients included in our study
differed substantially from prior trials. First, the mean age
of our cohort was more than 10 years older than these
clinical trials and we had significantly higher proportion
of women at 40% as compared with these three trials that
ranged from 27% to 32%. Second, we included patients
who had prior MI in the past 10 years while VALIANT
and OPTIMAAL were trials of acute MI with heart failure.
Finally, the use of statins has substantially increased where
we observed 84% prescription in our cohort; the OPTI-
MAAL trial reported only about 30% were prescribed
statins.12
An emerging number of observational studies have
suggested that outcomes of patients treated with ARBs
may have better outcomes compared with ACEIs.24–26
Using the Reduction of atherothrombosis for Continued
Health registry, Potier and colleagues performed an anal-
ysis including 40 625 patients who were at high cardio-
vascular risk and found a 10% reduction in the risk of
a composite of cardiovascular mortality, MI, stroke
or hospitalisation with ARB compared with ACEI at 4
years.26
Similarly, Padwal et al evaluated 87 772 diabetic
patients without prior MI using a large US claims data-
base and found that ARBs were associated with a 10%
reduction in all-cause mortality and all-cause hospitalisa-
tion.25
A smaller study from Korea also demonstrated that
ARBs may be associated with improved clinical outcomes
in patients with MI without heart failure or ventricular
dysfunction.24
By focusing on patients with prior MI,
our study adds to the contemporary literature to suggest
potential benefits associated with ARBs as compared with
ACEIs.
Sex difference of ACEI and ARB
We are unaware of any studies that have evaluated
the potential sex difference between ACEIs and ARBs
among patients with coronary artery disease. An obser-
vational study that evaluated sex difference between
ACEIs and ARBs in patients with heart failure also found
that women had significant survival improvement with
ARBs, but not in men.27
In our study, we found that
women were prescribed lower dose of ramipril relative
to men. Second, we also found that women have greater
adherence to ARBs as compared with ACEs. Others have
postulated that women have greater response in blood
pressure reduction in ARBs as a potential mechanism
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Table 3 Clinical outcomes at 3 years in the ACEI and ARB group in prespecified subgroups*
ACEI rate % (95% CI) ARB rate % (95% CI) HR (95% CI)† Interaction p value
Age (years)
75 10.3 (9.8 to 10.7) 10.1 (9.4 to 10.8) 1.02 (0.93 to 1.12) 0.155
≥75 20.4 (19.9 to 20.9) 18.8 (18.0 to 19.6) 1.10 (1.04 to 1.17)
Sex
Female 18.0 (17.4 to 18.6) 15.6 (14.7 to 16.5) 1.17 (1.10 to 1.26) 0.001
Male 14.6 (14.1 to 15.0) 14.7 (14.0 to 15.4) 1.00 (0.93 to 1.06)
Prior diabetes
Yes 18.9 (18.4 to 19.5) 18.1 (17.2 to 19.0) 1.05 (0.99 to 1.12) 0.576
No 13.5 (13.0 to 14.0) 12.6 (11.9 to 13.3) 1.08 (1.01 to 1.17)
Prior heart failure
Yes 28.7 (27.8 to 29.6) 26.4 (25.1 to 27.8) 1.12 (1.04 to 1.20) 0.209
No 11.7 (11.4 to 12.1) 11.2 (10.7 to 11.8) 1.05 (0.98 to 1.12)
*Primary outcome defined as cardiovascular death, rehospitalisation for myocardial infarction and unstable angina.
†ARB inhibitor was the reference group.
ACEI, ACE inhibitor; ARB, angiotensin receptor blocker.
of sex difference, and there is a diminishing effect of
ACEI in women over time.28
However, since this was an
incidental finding, we are cautious with respect to its
interpretation and suggest future study for additional
investigations.
Study limitations
Several potential limitations of our study merit considera-
tion. First, despite the availability of a large amount of clin-
ical detail and using sophisticated propensity weighting,
it is still possible that the difference we observed between
the treatment groups was a result of selection bias.
However, the influence of selection bias is likely to be
greater in studies comparing an active intervention with
no treatment than in studies like ours that compared
two active interventions with similar indications. Further-
more, in our study, patients prescribed ARBs were sicker
prior to propensity weighting, as they were older and had
more comorbidity, indicating that ARBs were not selec-
tively prescribed to lower-risk patients with MI. Second,
we did not have information regarding whether patients
were prescribed ARBs because of side effects associated
with ACEIs and whether they were prescribed as first-
line therapy. Therefore, our study should not be inter-
preted as advocating ARBs should be a first-line therapy
in patients with MI. Third, due to the number of formu-
lations of ACEIs and ARBs on the market, we combined
medications into two groups so that we can perform our
analyses. Our finding may not be applicable to all juris-
dictions if the composition of these medications is vastly
different. Finally, our study only included patients over
65 years of age because of the unavailability of prescrip-
tion information on younger patients. Further studies
are needed to examine whether similar results are seen
among younger patients.
Conclusions
Although many are still concerned with an ARB–MI
paradox, our study of close to 60 000 patients with MI
should serve as reassurance that ARBs are not associated
with adverse outcomes compared with ACEIs. Potential
benefits of ARBs as compared with ACEIs in older women
with MI should be further evaluated.
Acknowledgements This study was supported by the ICES, which is funded by an
annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC).
Contributors All authors contributed substantially to the manuscript, drafted
the article or revised it critically for important intellectual content and gave final
approval for the submission.
Funding This study was funded by a grant (G-14-0005977) from the Heart and
Stroke Foundation (HSF) of Canada and a Foundation grant (FDN-154333) from the
Canadian Institutes of Health Research.
Disclaimer The opinions, results and conclusions reported in this article are those
of the authors and are independent from the funding sources. No endorsement
by ICES or the MOHLTC is intended or should be inferred. Parts of this material
are based on data and information compiled and provided by CIHI. The analyses,
conclusions, opinions and statements expressed herein are those of the authors
and not necessarily those of CIHI.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement Data may be obtained from a third party and are not
publicly available.
Open access This is an open access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non-commercially,
and license their derivative works on different terms, provided the original work is
properly cited, appropriate credit is given, any changes made indicated, and the use
is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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